Author + information
- Wen-Qin Guo, MD,
- Lang Li, MD, PhD∗ ( and )
- Qiang Su, MD, PhD
- ↵∗Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, 22 Shuangyong Road, Nanning, 530021, China
We read with interest the study by Palmerini et al. (1), recently published in the Journal. The authors performed a meta-analysis to meaningfully add to the ongoing debate on dual antiplatelet therapy (DAPT) duration. They concluded that, compared with shorter DAPT administration, longer DAPT administration had a higher risk of all-cause mortality because of increased bleeding-relative death; however, the shorter DAPT group had a DAPT duration of 3 to 12 months. Although shorter DAPT administration was suggested to be associated with lower risk of all-cause mortality, given the heterogeneity of the definition of “shorter DAPT” group among trials (3 to 12 months), these studies do not allow an optimal duration to be identified.
To find out, we performed a network meta-analysis to compare the cardiovascular outcome among the ≤6-month, 12-month, and ≥18-month groups. All outcomes were expressed as hazard ratios (HRs) and their corresponding 95% credibility intervals (CrIs). Four chains were fit, yielding 400,000 iterations generating the posterior distributions of model parameters. The goodness of fit of the model was assessed by calculating residual deviance (2). The analysis was conducted by means of gemtc, rjags in R software, version 3.2.0 (Vienna, Austria) (3).
The results are shown in Figure 1. Compared with the 12-month DAPT, a nonsignificant harm for all-cause mortality was seen for the ≥18-month DAPT (HR: 1.14; 95% CrI: 0.93 to 1.40), whereas the ≤6-month DAPT was comparable (HR: 0.92; 95% CrI: 0.72 to 1.18). Patients treated with ≤6 months of DAPT were associated with nonsignificant higher risk of all-cause mortality than patients given ≥18 months of DAPT (HR: 0.81; 95% CrI: 0.62 to 1.06). In terms of the cardiac mortality, no difference was observed among the 3 DAPT duration groups. Relative to the 12-month group, patients treated with DAPT ≥18 months were associated with significantly increased risk of noncardiac mortality (HR: 1.46; 95% CrI: 1.05 to 2.03), whereas patients given DAPT for ≤6 months was not (HR: 1.00; 95% CrI: 0.67 to 1.50). No significant benefit was seen for bleeding-relative death for the ≤6-month DAPT group (HR: 0.62; 95% CrI: 0.33 to 1.18) or the ≥18-month DAPT group (HR: 1.22; 95% CrI: 0.73 to 2.07). Patients treated with ≤6 months of DAPT were associated with lower risk of bleeding-relative death than patients given ≥18 months of DAPT (HR: 0.50; 95% CrI: 0.26 to 0.98).
Overall, the risk of all-cause mortality was not different between the ≤6-month and 12-month DAPT groups. However, the ≥18-month DAPT group was associated with numerically higher all-cause mortality risk than the 12-month DAPT group, which was driven by increased risk of noncardiac death. Additionally, the ≥18-month DAPT group was associated with numerically higher all-cause mortality risk than the ≤6-month DAPT group, which was driven by bleeding-relative death.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation